Norfolk and Suffolk NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we did not rate this key question. At this assessment the rating was good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trusts overarching vision was "Improving together to provide safer, kinder and better care". Staff were aware of the trusts vision, which was displayed on computers and across wards.

Staff spoke of a positive culture and from our observations we witnessed a positive culture on the ward. Staff said they felt respected and valued in their role on the ward.

Staff had the opportunity to contribute to discussions about the strategy for their service, at regular team meetings.

The trust had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders, including ward managers and senior leaders, embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leadership development opportunities were available, including opportunities for staff. There were examples of staff that had worked at the hospital for several years who had progressed onto new career development opportunities within the hospital.

The trust fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they knew how to raise a concern and felt comfortable doing so. They were aware of the service’s whistleblowing policy and the Freedom to Speak Up Guardian. Staff had access to an external agency who provided a 24/7 confidential helpline. This allowed employees to speak to advisors who were not part of the trust’s internal management structure.

The trust valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust managed its diversity and inclusion through a central Equality, Diversity, and Inclusion (EDI) Strategy which aligned with the Public Sector Equality Duty under the Equality Act 2010.

The trust hosted several staff networks that provided "safe spaces" for colleagues to share lived experiences and influence trust policy, these included the Ability Network, LGBT+ Network, Women’s Network and the Race Equality and Cultural Heritage (REACH) Network.

The trust was in the process of rolling out anti-racism leadership programmes to senior managers to help them identify and challenge racial microaggressions and structural bias.

The trust maintained a zero-tolerance approach to racist abuse from both patients and staff, with processes for addressing such incidents.

Staff were able to apply to work flexibly, for example, to request flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role.

The trust had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We reviewed governance and staff meeting minutes. There was a clear framework outlining what must be discussed at staff and team meetings to ensure essential information, such as learning from incidents and complaints, was shared. The trust had clear governance processes in place to review and act on the results of audits, incidents and complaints.

The trust had a risk register at service level that accurately reflected the current risks. Managers and staff could access the risk register and raise concerns when required.

Staff had access to the equipment and information technology needed to do their work. The electronic prescribing system was highly effective and easy to use.

The trust had plans in place for emergencies including major incident contingency plans.

The trust understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The trust maintained community partnerships and worked with local organisations to support patient care.

Patients had access to Independent Mental Health Advocacy and Pets As Therapy (PAT) dogs were part of the therapeutic program for older people's mental health wards to reduce stress and improve patient engagement. Patients had access to external Speech and Language Therapy (SaLT), physiotherapists and dietitians.

The Intensive Older People's Service (IOPS) Provided "in-reach" support to inpatient wards. This ensured that community staff were familiar with a patient's progress before they were discharged.

Inpatient teams provided outreach to care homes in the region to offer psychological interventions and prevent unnecessary readmissions.

The trust actively collaborated with older adult mental health services in other NHS mental health trusts. These partnerships supported shared learning, the exchange of best practice, and service improvement through peer collaboration.

The trust focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Wards for older people with mental health problems had been involved with quality improvement initiatives, including the Falls Prevention Collaborative: A major initiative which ran from November 2023 to June 2025 across multiple inpatient wards aimed to reduce falls by 20%, which included daily risk huddles, medication reviews, and improved use of falls risk tools. Carers played a vital role in the Falls Collaborative, helping to review risk-management tools and ensuring changes were practical for families.

Wards carried out a "This is Me" Dementia Care: A project focused on increasing the completion of"This is Me"leaflets for dementia patients.

A trust-wide quality improvement collaborative launched in May 2025 to embed the Safewards model across all mental health inpatient wards by November 2026. This model aims to reduce conflict and containment on wards through co-produced interventions.

Recent upgrades to wards including Laurel Ward at Carlton Court have introduced brighter, more therapeutic environments, including female-only sitting rooms and improved garden access to aid recovery.